The new five-year framework for GP contract reform, which took effect from April, puts GPs at the heart of delivering more holistic, joined-up services closer to patients’ homes.
It will support some of the NHS’s key ambitions within the Long-term Plan, which has allocated £4.5 billion of funding for primary medical and community health services by 2023/24.
Primary Care Networks
The new framework, which is an agreement between NHS England and the British Medical Association’s General Practitioners Committee (GPC) in England, gives GP practices just under £1bn funding growth across five years, starting in April 2019.
A separate £1.8bn has been earmarked for Primary Care Networks (PCNs) – groups of practices that collaborate locally, in partnership with community services, social care and other providers of health and care services.
This money will come from Directed Enhanced Service (DES) payments, which are an extension of the core GP Contract. To qualify for the payments, GP practices must unite within PCNs by June 2019. The new PCN contract will be introduced from July 1.
PCNs which cover 30,000-50,000 people are the building blocks for Integrated Care Systems (ICSs), which cover a population of 1-3m. Fourteen ICSs are already up and running and the NHS wants such systems covering the whole of England by April 2021. Integrated Care Partnerships (ICPs), which cover approximately 500,000 people will sit in between ICSs and PCNs in the new hierarchy.
As well as delivering core GP services, PCNs will deliver a number of new services that are all linked to Long-term Plan priorities. Five of the services will start by April 2020, namely: structured medication reviews, enhanced health in care homes, anticipatory care (with community services), personalised care, and supporting early cancer diagnosis. The remaining two – cardiovascular disease case-finding and locally agreed action to tackle inequalities – will start by 2021.
Seven workstreams, which are part of ICSs, will be layered on top of the DES funded services, namely self-care and planned care; long-term conditions; frailty and end of life care; maternity and family; mental health; on the day care (emergency care) and cancer.
PCN staff and structure
In order to provide an extended range of services, PCNs will need to employ a wider variety of staff than might be feasible within individual GP practices. In fact, it is expected that GPs will eventually be outnumbered by other healthcare professionals who are expected to grow in number by 20,000 over the next five years, funded by the new GP contract DES payments.
The new staff will include additional clinical pharmacists, physician associates, first contact physiotherapists, community paramedics and social prescribing link workers. They will work across practices as part of a “network contract” for the seven new enhanced services and help to free up GPs to focus more on patients with complex needs. The NHS will fund 70 percent of the cost of most of the new roles with practices paying the rest. The NHS will also fully fund one social prescribing worker per network in year one.
All DES-related and other GPs services are likely to fall under the new GP contract and be provided via a PCN. PCNs will focus on service delivery, rather than planning and funding services; while ICPs focus on service development and management.
Each PCN is likely to have a GP as the clinical lead and they will be responsible for strategic and clinical leadership to help support change across primary and community health services, as well as overseeing service delivery.
Each service transformation workstream will probably be managed at an ICP level by a programme board. The programme and locality directors are likely to be drawn from CCGs which will have an increasingly strategic commissioning role. The ICP staff will support all the providers i.e. acute trusts, community, mental health and PCNs – in delivering the integrated service. How current primary care providers and federations fit into this model is still to be determined but it is likely to be via a sub contract from the PCN, which will be the centre of service delivery outside of a hospital setting.
New customers for pharma
It will, of course, be important for pharma to follow the progress of PCNs as they take shape across England and to map the new customers who will be emerging – from PCN leads to those in the new reimbursable roles that are being created. Industry also needs to map the new customers who will be working in ICPs and ICSs to help deliver the integrated care agenda.
Fundamentally, the health economy will be based on places, rather than organisations, with PCNs uniting service providers within neighbourhoods. Community specialist nurse teams, contracted by the community or acute trust, will work alongside practice teams. Practices will cross refer to the local GP with a specialist interest (GPSI), while formularies will be place based. However, there is still tension between hospital procurement and primary care FP10 costs.
Areas that worked as Vanguards, or have already morphed into ICSs, will be first off the blocks in putting the new GP contract into practice. Within about six months, we expect to see a more settled picture across England as pharma’s new customer groups become established in PCNs.
Steve How, Paul Midgley and Oli Hudson, of Wilmington Healthcare, explain how the new GP contract will shape local joined-up systems